Engaging community pharmacists in quality improvement (QI): a qualitative case study of a partnership between a Higher Education Institute and Local Pharmaceutical Committees.

BACKGROUND: Quality improvement (QI) involves the use of systematic tools and methods to improve the quality of care and outcomes for patients. However, awareness and application of QI among healthcare professionals is poor and new strategies are needed to engage them in this area. OBJECTIVES: This study describes an innovative collaboration between one Higher Educational Institute (HEI) and Local Pharmaceutical Committees (LPCs) to develop a postgraduate QI module aimed to upskill community pharmacists in QI methods. The study explores pharmacist engagement with the learning and investigates the impact on their practice. METHODS: Details of the HEI-LPCs collaboration and communication with pharmacist were recorded. Focus groups were held with community pharmacists who enrolled onto the module to explore their motivation for undertaking the learning, how their knowledge of QI had changed and how they applied this learning in practice. A constructivist qualitative methodology was used to analyse the data. RESULTS: The study found that a HEI-LPC partnership was feasible in developing and delivering the QI module. Fifteen pharmacists enrolled and following its completion, eight took part in one of two focus groups. Pharmacists reported a desire to extend and acquire new skills. The HEI-LPC partnership signalled a vote of confidence that gave pharmacists reassurance to sign up for the training. Some found returning to academia challenging and reported a lack of time and organisational support. Despite this, pharmacists demonstrated an enhanced understanding of QI, were more analytical in their day-to-day problem-solving and viewed the learning as having a positive impact on their team's organisational culture with potential to improve service quality for patients. CONCLUSIONS: With the increased adoption of new pharmacist's roles and recent changes to governance associated with the COVID-19 pandemic, a HEI-LPC collaborative approach could upskill pharmacists and help them acquire skills to accommodate new working practices.

New Models of Care: How Pharmacists Can Provide Better Care at Lower Costs.

Pharmacists, highly trained and accessible health care professionals, continue to be underused in American communities. Helping pharmacists to make the best use of their extensive clinical education and skills is a primary focus for the discipline's leaders. The University of Connecticut School of Pharmacy's PRISM initiative ( PeRformance I mprovement for Safe Medication Management) creates opportunities to partner with other health professionals or programs to advance the pharmacist's role in the community. All stakeholders must understand the evolving health care climate as society moves toward "health care without walls" (i. e., health care that is innovative, convenient, and likely to be entirely different than previous models). This article discusses progress made in Connecticut to advance pharmacy practice and describes programs that, if replicated in other areas of the country, could significantly improve care for vulnerable populations, especially the elderly. Programs that have been especially useful have emphasized the difference between needing medical versus pharmacy services, and approached provision of care in entirely new ways.

Mapping pharmacy deserts and determining accessibility to community pharmacy services for elderly enrolled in a State Pharmaceutical Assistance Program.

OBJECTIVES: Limited studies have investigated geographic accessibility to a nearby community pharmacy for elderly which is an essential determinant of the access to medications and pharmacy services. This research identified pharmacy deserts and investigated availability of different types of community pharmacies and their services for elderly enrolled in a State Pharmaceutical Assistance Program (SPAP). METHODS: The state of Pennsylvania in the US was used as a case to demonstrate the geographic accessibility to community pharmacy and services for elderly enrolled in SPAP. The locations of community pharmacies and households of elderly enrolled in SPAP were derived from Pharmaceutical Assistance Contract for the Elderly programs' database. The street addresses were geocoded and the distance to a nearby community pharmacy was calculated for study sample using the haversine formula. The demographic and geographic data were aggregated to Census Tracts and pharmacy deserts were identified using the predefined criteria. Descriptive statistical analysis was used to determine whether there are statistical differences in the socio-demographic profiles and distribution of different types of community pharmacies and their services in pharmacy deserts and non-deserts. This research used hot spot analyses at county level to identify clusters of pharmacy deserts, areas with high concentration of different racial/ethnic groups and clusters of high densities of chain and independent pharmacies. RESULTS: The Spatial analysis revealed that 39% and 61% Census Tracts in Pennsylvania were pharmacy deserts and non-deserts respectively (p < 0.001). Pharmacy deserts were found to have significantly more females, married and white elderly and fewer blacks and Hispanics compared to pharmacy non-deserts. Pharmacy deserts had significantly fewer chain and independent pharmacies and less delivery and 24-hour services in pharmacies than pharmacy non-deserts. Hot spot analyses showed that clusters of pharmacy deserts were more concentrated in southcentral, northwest and northeast regions of the state which represent rural areas and overlapped with clusters of high concentration of white individuals. CONCLUSIONS: The findings suggest that urban-rural inequality, racial/ethnic disparity and differences in availability of pharmacies and their services exist between pharmacy deserts and non-deserts. The methodological approach and analyses used in this study can also be applied to other public health programs to evaluate the coverage and breadth of public health services.

Ethical responsibilities of pharmacists when selling complementary medicines: a systematic review.

OBJECTIVE: The widespread sale of complementary medicines in community pharmacy raises important questions regarding the responsibilities of pharmacists when selling complementary medicines. This study reviews the academic literature that explores a pharmacist's responsibilities when selling complementary medicines. METHODS: International Pharmaceutical Abstracts, Embase, PubMed, Cinahl, PsycINFO and Philosopher's index databases were searched for articles written in English and published between 1995 and 2017. Empirical studies discussing pharmacists' practices or perceptions, consumers' expectations and normative studies discussing ethical perspectives or proposing ethical frameworks related to pharmacists' responsibilities in selling complementary medicines were included in the review. KEY FINDINGS: Fifty-eight studies met the inclusion criteria. The majority of the studies discussing the responsibilities of pharmacists selling complementary medicines had an empirical focus. Pharmacists and consumers identified counselling and ensuring safe use of complementary medicines as the primary responsibilities of pharmacists. No formal ethical framework is explicitly employed to describe the responsibilities of pharmacists selling complementary medicines. To the degree any ethical framework is employed, a number of papers implicitly rely on principlism. The studies discussing the ethical perspectives of selling complementary medicines mainly describe the ethical conflict between a pharmacist's business and health professional role. No attempt is made to provide guidance on appropriate ways to resolve the conflict. CONCLUSION: There is a lack of explicit normative advice in the existing literature regarding the responsibilities of pharmacists selling complementary medicines. This review identifies the need to develop a detailed practice-specific ethical framework to guide pharmacists regarding their responsibilities when selling complementary medicines.

Practice of community pharmacists related to multivitamin supplements: a simulated patient study in Iran.

Background Multivitamin supplements are a subset of dietary supplements sold in pharmacies as over-the-counter medicines. Community pharmacists are regarded as responsible professionals and relied on for their safe practice and efficacy. Objective The aim of this study was to evaluate the counselling practices of community pharmacists relating to typical use, interactions, contraindications, and side effects of multivitamin supplements using simulated patients. Setting Ninety-seven community pharmacies in Kerman, Iran. Method Two male students acted as simulated patients who role-played a scenario in the community pharmacies in two steps. In step 1, they spontaneously mentioned they were a student and did not eat properly through lack of time and requested a multivitamin supplement. In Step 2, if the pharmacists did not request a drug history, they would explain that they had severe acne and had been taking oral isotretinoin for a month. The counselling practice of the pharmacists was audio recorded. Main outcome measure The number of pharmacists who provided information about multivitamin use and identified isotretinoin-vitamin A interaction. Results Thirteen pharmacists in charge were absent at the time of the purchases. None of the pharmacists provided information about contraindications and side effects of multivitamin products. Twenty pharmacists provided instruction for multivitamin use, and two pharmacists took a drug history. In Step 1, only two pharmacists identified isotretinoin-vitamin A interaction, but in Step 2, this number increased to 15. Conclusion The counselling practice of pharmacists should be improved to promote effective and safe use of multivitamin supplements.

Primera guía clínica basada en la evidencia médica para la suplementación con probióticos en la farmacia comunitaria española / First clinical guide based on medical evidence for probiotic supplementation in Spanish community pharmacies

Se ha elaborado la primera guía clínica española que permitirá a los farmacéuticos comunitarios y demás profesionales de la salud seleccionar, para cada indicación específica, el producto con probióticos adecuado, la dosis y la vía de administración. Con ello se pretende lograr que la práctica diaria de indicación farmacéutica de los suplementos probióticos esté basada en las mejores evidencias científicas disponibles

We have developed the first Spanish clinical guide that will allow the community pharmacists and other health care professionals easily select the right product with probiotics, dosage and format for each specific indication. With the proposed guide, it is our goal that the daily pharmaceutical practice of probiotics supplementation in community pharmacy is based on the best scientific evidence available (AU)

Impact of medication therapy management in patients with Parkinson's disease.

BACKGROUND: Since the new German Apothekenbetriebsordnung was released, medication therapy management (MTM) has increased in importance. MTM is intended to improve the quality of life of patients. OBJECTIVES: The aim of this study was to improve the quality of life of patients with Parkinson's disease through an MTM by a community pharmacist. SETTING: The patients were recruited in cooperation with the Deutsche Parkinson Vereinigung e.V. (dPV) in Germany. Methods All patients were evaluated at baseline (t0) and after a follow-up of 4 months (t1). During the intervention period, the pharmacists implemented an MTM with standardized pharmaceutical care. Main outcome measure The effects of the interventions were measured by the Unified Parkinson Disease Rating Scale (UPDRS) and the Movement Disorder Society Unified Parkinson Disease Rating Scale (MDS-UPDRS). RESULTS: In this study, 90 patients with Parkinson's disease were included. The most common intervention was to find a therapy for untreated comorbidities. The UPDRS or MDS-UPDRS improved significantly after the intervention period by a median change rate of 1 (p < 0.05) or rather 2 (p < 0.05) compared to the baseline. CONCLUSION: The study shows that the quality of life in Parkinson's disease patients improved significantly through MTM.

What risks do women face when seeking advice during pregnancy from pharmacies and natural health retailers?

AIM: Potential risks to mother and foetus exist with the incorrect use of complementary and alternative medicine (CAM) products during pregnancy. This study aimed to identify the risks that a woman may face when seeking advice during pregnancy from pharmacies and health food stores (HFS) in Greater Wellington (New Zealand). METHODS: 21 HFS and 21 geographically-matched pharmacies were visited by a researcher who sought advice regarding vitamin supplementation and nausea in early pregnancy using a standardised scenario. Any advice given, including details of recommended products, was documented immediately upon leaving the premises. Proportions were obtained and paired contingency table analysis was used to examine the agreement between the matched pairs. RESULTS: A minority of pharmacies (5/21, 23.8%) and HFS (1/21, 4.8%) made primary recommendations for nausea which were supported by Ministry of Health (MOH) guidelines, and both pharmacies (14/21, 66.7%) and HFS (7/21, 33.3%) recommended products contrary to these guidelines. A greater proportion of pharmacies gave advice consistent with MOH recommended dosage of folic acid supplementation than HFS (20/21, 95.2% vs 10/21, 47.6%). 2/21 (9.5%) of pharmacies and 4/21 (19%) of HFS gave advice with a potential risk of vitamin A overdose. CONCLUSIONS: Pharmacies and HFS in Greater Wellington provided potentially hazardous advice, recommending products, often branded for pregnancy, which contradicted NZ MOH guidelines. Regulatory reform of CAM products and those who sell them is called for in New Zealand.

Un enfoque holístico e integrado de la implantación de los servicios farmacéutico cognitivos / A holistic and integrated approach to implementing cognitive pharmaceutical services

La Farmacia Comunitaria forma parte del sistema de salud. Este sistema actualmente se encuentrasometido a presiones económicas y debe afrontar cambios en la demanda tanto de los consumidorescomo de los gobiernos. La respuesta de la profesión farmacéutica está dirigida a orientar su prácticahacia el paciente y a implantar servicios cognitivos farmacéuticos (CPS). En distintos países estosservicios tiene objetivos similares aunque presentan diferencias en el énfasis de los servicios, en susdefiniciones, denominaciones y en la utilización de diferentes herramientas. Sin embargo, todos ellospueden clasificarse utilizando un amplio modelo jerárquico que se basa en la toma de decisionesclínicas y en la amplitud del cambio requerido. (Box 1). Los retos que debe afrontar la profesión estánrelacionados con el desarrollo de un nuevo modelo de farmacia orientado al paciente que afecta a laspolíticas de salud, a la formación e investigación, a la evolución de los mercados, a los abordajes delcambio tanto a nivel individual como organizacional, y a la implantación de CPS. Estos temas y lainvestigación en práctica farmacéutica que se ha venido realizando con anterioridad han sidosintetizados para proporcionar una plataforma para el cambio que pueda guiar un planteamientoholístico e integrado de implantación de CPS. Conceptualmente la implantación de CPS puedeenmarcarse en seis niveles: clínico, provisión de servicios, farmacia comunitaria, organizaciónprofesional, gobierno y agentes implicados (Figura 1). La experiencia reciente relacionada con laimplantación de servicios ha mostrado la aplicación de programas de implantación que han incluidouno o dos de estos niveles en lugar de haber utilizado un abordaje holístico. Por ello se ha desarrolladoun modelo concéntrico para ilustrar la implantación de CPS dentro del planteamiento integrado yholístico necesario para apoyar el cambio En España se ha desarrollado un programa (conSIGUE) quepretende integrar los seis niveles con el objetivo de apoyar la implantación y evaluación de un CPS, elservicio de seguimiento farmacoterapéutico

Community pharmacy is part of the health care system which is currently under economic pressureand facing changes in demands from consumers and government. In response, the pharmacyprofession is becoming more patient orientated and implementing cognitive pharmaceutical services(CPS). CPS in various countries has similar objectives with different emphasis, definitions, labels andBENRIMOJ S.I. Enfoque holístico e integrado de la implantación de los servicios farmacéutico… 70Ars Pharm, 51-2; 69-88.using different tools. However, they can be classified using a broad hierarchical model based onclinical decision making and the extent of change required (Box 1). The challenges faced by theprofession are related the development of a new patient orientated model of pharmacy which affectshealth care policy, education and research, the evolution of the market, the individual andorganisational approaches to change and the implementation of CPS. These issues and previousresearch conducted in pharmacy practice have been synthesised to provide a platform for change thatcan guide a holistic and integrated approach to CPS implementation. Implementation can beconceptually framed in six levels: clinical, service provision, community pharmacy, professionalorganisation, government and stakeholder (Figure 1). Past experience with service implementation hasseen the application of programs that include one or two of these levels in practice rather than aholistic approach. A concentric model was developed to illustrate the implementation of CPS and theholistic and integrated approach required to support change. A program (conSIGUE) being conductedin Spain has attempted to integrate all six levels to support the implementation and evaluation of amedication management service (Seguimiento Farmacoterapéutico)

User satisfaction with pharmacy services in the Brazilian National STD/AIDS Program: validity and reliability issues.

The objective of this study is to evaluate the psychometric properties of a user satisfaction scale regarding the Brazilian National STD/AIDS Program, specifically related to dispensing AIDS medicines. The scale was developed and applied in a study covering 10 Brazilian States that evaluated the quality of medicine dispensing. The questionnaire was answered by 1,412 people living with HIV and undergoing antiretroviral therapy. Construct validation involved two stages of factor analysis. The item-total correlation matrix was analyzed, and tests for associations between the target variable, socio-demographic variables, and related constructs were performed. Reliability was studied by means of the sub-scales' internal consistency, estimated by Cronbach's alpha. Five relevant satisfaction dimensions were identified. A moderate level of internal consistency was found for these dimensions, suggesting they were adequate. The results of the association tests agreed with other studies reported in the literature. We conclude that the instrument is appropriate for application in similar populations with adequate psychometric characteristics and serves to measure users' assessments of the pharmaceutical services received and helps to orient improvements in such services.

User satisfaction with pharmacy services in the Brazilian National STD/AIDS Program: validity and reliability issues / Satisfação de usuários do Programa Nacional de DST/AIDS com a dispensação de medicamentos: aspectos de validade e confiabilidade

The objective of this study is to evaluate the psychometric properties of a user satisfaction scale regarding the Brazilian National STD/AIDS Program, specifically related to dispensing AIDS medicines. The scale was developed and applied in a study covering 10 Brazilian States that evaluated the quality of medicine dispensing. The questionnaire was answered by 1,412 people living with HIV and undergoing antiretroviral therapy. Construct validation involved two stages of factor analysis. The item-total correlation matrix was analyzed, and tests for associations between the target variable, socio-demographic variables, and related constructs were performed. Reliability was studied by means of the sub-scales' internal consistency, estimated by Cronbach's alpha. Five relevant satisfaction dimensions were identified. A moderate level of internal consistency was found for these dimensions, suggesting they were adequate. The results of the association tests agreed with other studies reported in the literature. We conclude that the instrument is appropriate for application in similar populations with adequate psychometric characteristics and serves to measure users' assessments of the pharmaceutical services received and helps to orient improvements in such services.

O objetivo do presente artigo é avaliar propriedades psicométricas de uma escala de satisfação de usuários do Programa Nacional de DST/AIDS com a dispensação de medicamentos. A escala foi desenvolvida e aplicada num estudo abrangendo dez estados brasileiros para avaliar a qualidade da dispensação de medicamentos. O questionário foi respondido por 1.412 pessoas vivendo com HIV em tratamento com anti-retrovirais. Para validação de constructo, foram realizadas duas etapas de análise fatorial. A matriz de correlação item-escala corrigida foi analisada; testes de associação entre a variável de interesse, variáveis sócio-demográficas e constructos relacionados foram realizados. A confiabilidade foi estudada por meio da consistência interna das subescalas, estimada pelo alpha de Cronbach. Cinco dimensões da satisfação foram identificadas. Encontrou-se consistência interna moderada para essas dimensões, sugerindo adequações. Houve concordância entre os resultados dos testes de associação realizados e os achados de outros estudos descritos na literatura. O instrumento mostrou-se apropriado para ser aplicado em populações semelhantes, servindo para aferir a avaliação dos usuários sobre os serviços recebidos e assim orientar melhorias nos serviços avaliados.

High blood pressure advice given by natural health food stores.

AIM: Complimentary and alternative medicines are widely used but are not registered medicines. The aim of the study was to compare advice given by health food stores and pharmacists for hypertension. METHODS: Twenty-six health food stores and 26 pharmacies were visited by an individual for advise on a hypothetical problem of hypertension. RESULTS: Staff in 25 out of 26 health food stores did not refer the researcher to a medical practitioner; instead they recommended and sold a wide variety of compounds of unproven efficacy. CONCLUSIONS: We recommend the implementation of a formal training programme for health food stores staff and that complimentary and alternative medicines-use in New Zealand is regulated.

STI management in Tanzanian private drugstores: practices and roles of drug sellers.

OBJECTIVES: To describe the role and possible contribution of private drugstores in sexually transmitted infection (STI) management in rural Tanzania. METHODS: A cross-sectional study that included drug sellers in private drugstores in eight districts of Tanzania. Data collected through interviews with drug sellers and the simulated client method presenting a male and female STI case. "QATI" scores (Questions, Advice, Treatment and drug Information) were developed to describe overall STI management. RESULTS: Although 74% of drug sellers stated that there were no STI-related drugs in the store, medications were dispensed in 78% of male and 63% of female simulated client visits. The clients were dispensed drugs recommended in the Tanzanian guidelines for syndromic management of urethral or vaginal discharge in 80% of male and 90% of female cases. Drug sellers dispensed antibiotics during 76% of male and 35% of female simulated client visits. Dosage regimens were often incorrect and complete syndromic management rarely provided. Most drug sellers agreed that it is within their professional role to give information on STI treatment (89%) and prevention (95%). Drug-use information was almost always provided. Advice was however seldom given and questions occasionally asked. Overall STI management was better for men than for women. CONCLUSIONS: The drug sellers, although aware of the prescription-only status of antibiotics, saw themselves as having a role in STI management and were ready to provide drugs. In this resource-limited setting, drug sellers could provide effective and safe STI management especially to male patients if given appropriate tools to improve practice. The consequences of this for official policy need to be discussed.

Community identification of natural health product-drug interactions.

BACKGROUND: The majority of Canadians use natural health products (NHPs), most of which are purchased in pharmacies. Community pharmacists regularly field inquiries regarding NHPs. As such, pharmacists are ideally placed to answer questions about NHP use and interactions with other medications. OBJECTIVE: To identify community pharmacists' familiarity with NHPs and NHP-related adverse events (AEs) and their knowledge and ability to counsel on potential and known NHP-drug interactions. METHODS: Survey questions were derived from a literature review of previous surveys, data collected from Health Canada, and in consultation with clinicians, pharmacists, policy-makers, and researchers. A convenience sample of 321 community pharmacists in Alberta and British Columbia were asked to participate. RESULTS: We received responses from 132 pharmacists, resulting in a response rate of 41% (132/321). A total of 19% of the sample had previously reported an adverse event to Health Canada. When asked specifically about NHP-drug interactions/AEs, 47% of pharmacists stated that they had identified a potential interaction; however, only 2 of these reported it to Health Canada. Pharmacists were most familiar (76% of respondents) with the interaction between sertraline and St. John's wort and were least familiar with interactions between NHPs and anti-retrovirals. CONCLUSIONS: This survey provides evidence to suggest that pharmacists encounter reportable NHP-drug interactions, yet rarely choose to report these events. The current lack of available data on NHP AEs makes it difficult to provide patients and healthcare providers with useful strategies for managing AEs and drug interactions. Changes to the current system of monitoring AEs due to NHPs and further education of healthcare professionals regarding NHP-drug interactions is required.

Nonprescription drug therapy: issues and opportunities.

Nonprescription drug therapy is tightly woven into the fabric of American health care. Market forces are expected to contribute to significant expansion of nonprescription drug use. Consumers place high value on nonprescription drug therapy; however, self-medicating patients frequently need assistance from a learned intermediary to assure optimal integration of nonprescription drug therapy into the total care regimen. Pharmacist-assisted self-care holds vast potential to serve the public interest, but this expanded practice role will require higher levels of professional practice commitment by American pharmacy. That commitment must be supported by practice-relevant, competency-based, patient-centered college and school of pharmacy curricula and continuing education that assures perpetual intellectual proficiency in nonprescription drug pharmacotherapy. That knowledge and competency must be integrated holistically into the total mix of patient comorbidity and polypharmacy. The pharmacist-assisted self-care business and professional practice model must be further facilitated by state and national pharmacy organizations, chain and independent community pharmacy, pharmacy wholesalers, and others. Consumers await expanded and differentiated pharmacy-based, pharmacist-provided medication therapy management services focused on the safe, appropriate, and effective selection, use, and monitoring of nonprescription drugs therapy.

[Aiming toward the supply of aseptic drugs--up to acceptance of the first patient].

As the ageing society has come, a categorized medical function has been advanced. Therefore, an improvement of medical care service for home care patients has been requested. One of the services provided by community pharmacists was to visit patient to give drug management advice based on the medical insurance and homecare insurance guidelines. In 1994, the Ministry of Health and Welfare expressed a degree of pharmacist's involvement to share patient's concern and was described as "the maturity of pharmacy". At present, the third step in the division of labor in medical services has taken its root. Then, an effort to arrange the fourth step (supply of aseptic drugs) will be needed in the future. Clinical exercises by pharmacists, acquisition of aseptic preparation skills and maintenance of facilities like a clean room will be required because the supply of aseptic drugs will be the first experience for a pharmacy. Neighboring medical facilities have to be prepared for accepting a supply of aseptic drugs along with the pharmacy's preparation. This time, we could have had an opportunity to accept the HPN patient. So we would like to report our progress and challenge.

Ability of clinical pharmacists in a community pharmacy setting to manage anticoagulation therapy.

OBJECTIVES: To determine the ability of community pharmacists within an anticoagulation clinic to keep international normalized ratios (INRs) within therapeutic ranges and, secondarily, to determine the incidence of bleeding and thromboembolic events and patient satisfaction. DESIGN: Retrospective observational study. SETTING: Eckerd PatientCARE Network in Eckerd pharmacies in Tampa Bay area of Florida. PATIENTS: 50 patients taking warfarin and having INR determinations for 6 consecutive months. INTERVENTIONS: Clinical pharmacists monitored patients' anticoagulation status using point-of-care analyzers and making dosage changes as needed under a collaborative agreement. Extensive patient education was provided to patients regarding their anticoagulation. Data were collected from the initial visit through the 6 consecutive months. Patients were surveyed to assess their satisfaction with the clinic. MAIN OUTCOME MEASURES: Percentage of INRs within therapeutic range and, secondarily, incidence of bleeding and thromboembolic events and patient satisfaction with the clinic. RESULTS: During the 6 months of initial therapy with warfarin, 243 of 435 (56%) INRs were in desired therapeutic ranges. A total of 15 bleeding episodes were reported, of which 10 were minor and 5 were significant. No thromboembolic events were reported. There was a 22% response rate to the survey, in which all statements were rated as above average to excellent. CONCLUSION: Community pharmacists in an anticoagulation clinic effectively manage anticoagulation therapy, as the results of this clinic are similar to those of clinics managed by pharmacists in other settings.

Medical pluralism in action? A case study of community pharmacies in Johannesburg, South Africa.

OBJECTIVES: The main aim of this study was to examine whether, and to what extent, community pharmacies have become sites for the practice of complementary and alternative medicine (CAM) as an example of "medical pluralism." METHODS: Qualitative as well as quantitative methods such as a telephone survey of all pharmacies in Johannesburg, observations, and in-depth interviews with pharmacists and CAM healers were used. RESULTS: The evidence presented in this paper, although based on a study of community pharmacies in Johannesburg only, can be interpreted as an indication of a general trend in urban areas in South Africa, that of involvement with CAM in the form of dispensing and sales of CAM products, provision of advice, and, in a few cases, employment of CAM practitioners to consult on their premises. Thus the two systems of CAM and allopathic medicine are being practiced within the same premises. However, the manner in which they operate, as portrayed in this study, is that of two separate systems existing in relative harmony side-by-side. CONCLUSION: Because of the constraints of the study, it is difficult to ascertain to what extent this is a first step toward the development of a more meaningful integration between the systems. It is much easier to demonstrate that this growth is driven by the pharmacists' response to the growing demand from the public and their readiness to seize the opportunity to expand their responsibilities and increase their profits. This is supported by the willingness of CAM healers to participate in the endeavor.

Effect of technical and functional quality on patient perceptions of pharmaceutical service quality.

PURPOSE: To evaluate the relative importance of functional quality (how services were provided) and technical quality (what was received for those services) on patient perceptions of pharmaceutical service quality. METHODS: A scenario-based experimental design was chosen to manipulate functional (FQ) and technical quality (TQ). Subjects were asked to read one of four scenarios describing a pharmacy service experience and imagine that he or she were in the situation described. High and low TQ were manipulated by describing the presence or absence of a prescription medication dispensing error made by the pharmacist in the scenario. Each subject completed a survey about their evaluations of the service provided in the scenario. An ANOVA using a 2 x 2 completely randomized factorial design was conducted to compare the effects of TQ, FQ, and their interaction on perceptions of service quality and behavioral intention. Effect sizes were measured with the calculation of omega-square. RESULTS: FQ had the greatest impact on patient perceptions of service quality and behavioral intentions. FQ explained 44% of the variance in service quality and 39% in intention to return. TQ and the interaction accounted for a significant but much lesser effect. The interaction showed that the effect of FQ was greatest under conditions of high TQ. There were no significant associations between any demographic characteristics and responses to service quality. CONCLUSIONS: The results suggest that FQ has the greatest impact on consumer perceptions of pharmaceutical service quality even under conditions of an obvious example of low TQ which respondents perceive as serious and possibly harmful. This study underscores the limitations of relying on patient perceptions in evaluating pharmaceutical services. Although patient evaluations are important, they can be inadequate for assessing the professional quality of services.

Patterns of antimicrobial use and antimicrobial resistance among healthy children in Bolivia.

OBJECTIVE: To determine the incidence of antimicrobial-resistant, nonpathogenic Escherichia coli among healthy children aged 6-72 months in Camiri town and a rural village, Javillo, in south-eastern Bolivia. METHOD: A community-based survey: stool samples were obtained from 296 healthy children selected by modified cluster sampling in Camiri and all 25 eligible children in Javillo. E. coli isolates were tested for antimicrobial susceptibility according to the standard disc diffusion method. By a questionnaire survey of 12 pharmacies and by using simulated patients, we investigated the antimicrobial availability and the usage patterns in Camiri town. RESULTS: In Camiri, over 90%, and in Javillo over 70% of children carried E. coli resistant to ampicillin, trimethoprim-sulphamethoxazole (TMP/SMX) or tetracycline. Overall, 63% of children carried E. coli with multiple resistance to ampicillin, TMP/SMX, tetracycline and chloramphenicol. In the simulated patients study, antimicrobials were dispensed inappropriately for 92% of adults and 40% of children with watery diarrhoea, and were under-prescribed for males with urethral discharge (67%) or females with fever and dysuria (58%). The dose and/or duration of antimicrobials dispensed was almost always too low. CONCLUSION: Our study showed a disturbingly high prevalence of carriage of nonpathogenic E. coli resistant to antimicrobials. The prevalence of resistance to ampicillin and TMP/SMX was higher than that previously reported in developing countries. The existence of a large reservoir of resistance genes in healthy individuals in developing countries represents a threat to the success of antimicrobial therapy throughout the world. Programmes to improve rational and effective drug use in developing countries are urgently needed.